There have been 12 potentially deadly failures which have occurred in Devon hospitals and health providers in just eight months.

Classified as ‘never events’ because they are considered so serious they should never happen, they all took place between April and the end of November of last year.

The Royal Devon & Exeter Hospital (Image: Lewis Clarke / Geograph)

The trusts with the most never events in Devon were the Royal Devon and Exeter NHS Foundation Trust, and University Hospitals Plymouth NHS Trust - both of which had four.

Torbay and South Devon NHS Foundation Trust had two incidents, while three other providers experienced one incident each.

The data, published by NHS England, only gives an outline of the nature of each failure. They are counted in specific categories of error.

Never Events recorded in Devon between April 1 to November 30

Royal Devon and Exeter NHS Foundation Trust - 4

University Hospitals Plymouth NHS Trust - 4

Torbay and South Devon NHS Foundation Trust - 2

Northern Devon Healthcare NHS Trust - 1

Tavistock Community Hospital - 1

Two failures at the RD&E included surgery being performed on the wrong patient or the wrong part of the body. A third was recorded as “retained foreign object post procedure”.

It means items, which could include swabs, needles, instruments and guidewires, were left inside the patient's body after surgery or other medical procedures.

The final incident involved the misplacement of a tube running from either the mouth or the nose to the stomach which can carry a risk of death or severe harm.

Three failures at University Hospitals Plymouth, and one each at Torbay and South Devon, Northern Devon Healthcare NHS Trust, and Tavistock Community Hospital, involved surgery being performed on the wrong person or part of the body.

“On the rare occasion these events do take place, we immediately launch an investigation in line with a national framework and guidance, involving all relevant parties, including the care provider, and we involve the patient and their family.

“These investigations are important to understanding what has happened and why, and what learning we can take from it to ensure this never happens again.”

Lorna Collingwood-Burke

Across England there were 344 never events recorded, with the most common type of incident involving surgery being performed on the wrong person or on the wrong part of the body. Of those, 33 incidents involved dentists pulling out the wrong teeth.

In December, England’s chief inspector of hospitals called for a change in culture within the NHS to reduce the number of patients who experience avoidable harm. A report published by the Care Quality Commission (CQC) found that too many people were being harmed because of lack of training and the complexity of the current safety system.

How to download the Devon Live app

Click on the App Store here to download the app for iOS devices, and on the Google Play store here or download the app on Android.

Professor Ted Baker, CQC’s chief inspector of hospitals, said: “NHS staff do a remarkable job to keep patients safe, but despite their best efforts, never events and other patient safety incidents continue to happen.

“We know there is a strong commitment to patient safety within our NHS and we must support staff to give safety the priority it deserves, but there is a wider challenge for us all to effect the cultural change that we need to have the humility to accept that we all can make errors, so we must plan everything we do with this in mind.

“This change in approach is essential if we are to create a just culture where learning is shared, and where solutions are created proactively to manage risk.

“Only then will we be able to reduce the toll of never events and the much greater number of other safety incidents.”